A Ten-Year Analysis of Venous Thromboembolism on the Surgical Service: The Effect of Practice Guidelines for Prophylaxis

Abstract

Conclusion: High compliance with the American College of Chest Physicians (ACCP) Guidelines for Prophylaxis for Venous Thromboembolism has not resulted in a decrease in symptomatic venous thromboembolism (VTE) in surgical patients. Summary: The ACCP has published its Guidelines for Prophylaxis for Venous Thromboembolism about every 3 years since 1995, with the most recent version published in August 2008. There is currently intense interest in proving compliance with these guidelines to reduce the incidence of VTE in hospitalized patients. The effect on surgical patients of compliance or noncompliance with prophylaxis guidelines for VTE on morbidity and mortality is not known. In this series the authors sought to determine whether a decrease occurred in symptomatic VTE on their general surgical, vascular surgical, and trauma services since initial publication of the VTE prophylaxis guidelines. Care of patients with symptomatic VTE was analyzed for compliance or noncompliance with the guidelines, and reasons for noncompliance. The effect of VTE on short-term morbidity and mortality was also analyzed. The study used records of patients with symptomatic VTE on the general surgical, vascular surgical, and trauma surgical services at the University of Vermont for a 10-year period since publication of the 1995 ACCP guidelines. Morbidity of each episode of VTE was weighted based on likelihood of short-term mortality and long-term morbidity. There were 37,615 patients on the combined surgical services during the 10-year period of analysis, and a symptomatic VTE developed in 172 (0.46%). The incidence gradually increased during the years of the study. Partial or complete compliance with the guidelines was achieved in 84% of the patients. Of the VTEs that occurred, 37% were considered to be preventable, whereas 63% were judged nonpreventable based on full compliance with the guidelines or partial compliance associated with a documented contraindication to prophylaxis. Comment: The authors report one of the highest rates of compliance with ACCP guidelines for prophylaxis of VTE. Despite this, their rate of symptomatic VTE has increased during the 10-year period of the study. A number of factors may play a role in this increased incidence of symptomatic VTE. These include more aggressive pursuit of the diagnosis of pulmonary embolism or deep venous thrombosis and an increase in the comorbidity burden of patients undergoing surgical treatment. There is also the possibility that the prophylactic measures suggested by the guidelines are insufficient to prevent VTE in some high-risk patients.